COMPLETE AND BRING WITH YOU TO CHECK-IN

Medical/Liability RELEASE FORM

Name__________________________________________ Emergency Contact Number _____________________________

Gender ______________ Age ___________ Alternate Phone # (home or cell) ______________________________

Address _________________________________________ City _______________________ ST _______ Zip _______________

Email Address _______________________________________ Event Attending _______________________________

Medical Release: Should medical treatment be necessary for any participant, camp personnel will take the participant to a
hospital emergency room. Before treatment can be rendered, we must provide them with the medical information and a release form.
Please complete this form and sign below indicating your consent and permission for an authorized agent of Camp Highland to sign an
“Authorization for Emergency Treatment” for your child or ward on your behalf should medical treatment be necessary at the time of an
emergency that requires immediate care. If such treatment or injury should occur, you will be notified immediately. Please provide us
with your insurance information.

Medical History: Please CIRCLE any ailments or conditions to which the participant is subject:

Drug reactions/allergies ___________________________ Heart problems Respiratory problems

Allergies ____________________ Headaches Kidney problems Other (list below)

Please indicate any recent illnesses, injuries or conditions that may affect your participation:

Release of Liability: Camp Highland (Highland Day Camp, Highland Corporate Adventures) is an adventure challenge camp
that provides voluntary participation in strenuous and potentially dangerous activities. The risk of injury from the activities involved in
this program is significant, including the potential for permanent paralysis and death, and while the rules, equipment and personal
discipline may reduce the risk of serious injury, the potential of injury/death does exist. I assume full responsibility for my, and/or my
child’s participation. I willingly comply with the stated and customary terms and conditions of participation. If I however, observe any
unusual significant hazard during my presence or participation, I will remove myself and/or my child’s participation and bring such
attention to the nearest camp personnel immediately. I, for myself, or on behalf of my child, heirs, assignors and personal
representatives, do herby release and hold harmless Camp Highland, Highland Day Camp, Highland Corporate Adventures, Make a
Difference Ministries, Inc, or their officers, agents and/or employees, other participants, sponsoring agents, property owner(s), lessors
of premises used to conduct activities. I release Camp Highland with respect to any and all injury, disability, death, or loss of damage
to personal property. I also understand that pictures and/or video might be recorded during my time at camp and hereby permit Camp
Highland to make use of any photographs or video of me and/or my family for any promotional materials produced from those images.

I have read and understand this release of liability of risk agreement and sign it voluntarily.

Printed Name ________________________________________________

Participant’s Signature X ____________________________________________________ Date _________________

(if over 18 years of age)

Camp Highland 1200 Camp Highland Rd Ellijay, GA 30540 678-393-0300 camphighland.com